Lecture: Public Private Partnership (PPP) for Integrated Primary Eye Care

VISION 2020: The Right to Sight-INDIA Knowledge Hub Presents this Webinar.

Different international mandates recommend integrating primary eye care with primary health care to build a strong national, people-centred eye care programme. The World Report on Vision (2019) emphasised the need to make eye care an integral part of universal health coverage and incorporate integrated people-centred eye care (IPEC) in health systems as the strategy to achieve the same.

One of the major areas of focus for the global community is universal health coverage. Primary health care and integrated people-centred eye care are the necessary foundations for this effort. This webinar will explore the Public private partnership (PPP) models setup by CBM, RP Centre, AIIMS and Operation Eyesight Universal (OEU) respectively and discuss the major findings followed by the recommendations to integrate primary eye care.

Mr. Ravi Ranganathan, Head- Inclusive Health and Humanitarian Response, CBM
Dr. Praveen Vashist, Professor and Head of Community Opthalmology, RP Centre, AIIMS
Dr. Troy Cunningham, Country Manager, OEU.


[Phanindra] Hello, good evening everyone. I’m Phanindra, from Vision 2020: The Right to Sight-India. I welcome you to this webinar on Public Private Partnerships for Integrated Primary Eye Care. With in partnership with CBM India, Operation Eyesight Universal, And RP Center, and All India Institute of Medical Sciences. In this webinar we would like to discuss the scope of public private partnerships in primary eye care. And also discuss the PPP models implemented by CBM, Operation Eyesight Universal and RP Centre. And also some discussion will be happy if we could have it on how to scale up the ongoing models and the continue for care. We have Dr. Troy Cunningham, he’s a Country Director at Operation Eyesight Universal. He works in Southeast Asia including India, Nepal, Bangladesh, and Sri Lanka. And we have our second speaker, Mr. Ravi Ranganathan. Who is the Head of Health and Disaster response at CBM India. And not the least we have Dr. Praveen Vashist. He is a professor and Head of Community Ophthalmology at RP Centre, AIIMs. And also the vice president of Vision 2020: The Right to Sight-India. Thank you, once again, for your participation, thank you, everybody. And now I request Dr. Praveen Vashist to how we start please, thanks so much. [Praveen] Thank you for arranging this webinar through Vision 2020: The Right to Sight and giving me an opportunity to share experience of RP Center in relation to public private partnership for integrated primary eye care. Integrated primary eye care, most of us know that it is taken at the frontline activity which is providing care and identifying disease before it becomes a serious medical issue. In terms of the latest IPEC approach we can use specific term like it should be appropriate, it should be accessible, affordable, and a comprehensive primary eye care is needed in competent manners. And of course it should be for a lifetime of continuous care. As part of Vision 2020, we initiated this Vision 2020: The Right to Sight in 2004 and the RP Center was the founding member. In fact we have always been initiated and given importance to primary eye care. You can see this Vision 2020 Eye Health Infrastructure Model that we started in 2004. Besides the centers of excellence, besides training centers and service centers, probably maximum goes to primary eye care in terms of vision center. And we thought that we should have one vision center for every 50,000 population in that. What happened, actually, after 16 years in 2020, what we realized is that initiative had been taken as far as training centers and service centers were concerned. But as far as vision centers, the primary eye care is grossly lacking that. Against a target of 20,000 centers, we have nearly just 4,000 vision centers in turn. As world vision report, as we can see that the number of blind people are increasing. In fact as for this report, there are nearly 2.2 billion visually impaired and among them at least 1 billion that need services for eye care services. Given this growing demand for eye care services the effective option is that we should have public private partnerships. But they’re good at the level of public domain sector, it should be adopted but the best can be provided by the private sectors and that should be arranged. And private means either a non profiting/profiting NGOs or NGOs or other public private sector which work for profit. We have seen good PPP models in trachoma control program and also for provision of spectacles. All primary eye care needs such models. As a strategy plan which has been developed by Vision 2020. We have five objectives and among these objectives the first foremost objective is universalization. That deals with providing a model for primary eye care. And we are looking for public private partnership model all over the country where the INGOs and the leading institute can take lead in providing such services. When I talk about primary eye care vision center, it means an eye care facility which is linked with the community. It is the first point of interface of the population with comprehensive eye care services. And one person, the ophthalmic assistant or optometrist or vision technician, whatever term you want to use, is the person who proves that exclusive skilled eye care. And of course, as I mentioned one side is linked with the community level workers and the other side it is linked with the second level hospitals who provide referral services. If we talk different models of primary eye care for vision centers, it can be fixed facility vision centers which is more commonly used. And we can also have mobile vision centers. Mobile vision centers with tele ophthalmology. In fixed vision centers there are two key models which have been used. One by most of the NGO partners, that is a stand alone primary eye care services and another is an integrated primary health center. In our country we have at present nearly 24,000 primary health centers which provide comprehensive health care services. And what we need is we can integrate eye care ophthalmics along with primary health centers and that is an integrated model which is being recommended by government of India. In the RP Center, I joined in 2003 and since then we are trying this primary eye care models. Initially we were working with various NGO partners. They were providing us infrastructure and we were providing services to them. With the sight savers in 2014, in ‘13-’16, we started another project where we tried to involve more and more government dispensaries. Integrated vision centers through government dispensaries that kind of model was developed. In fact, we identified the vulnerable population all over Delhi and with partnership with Delhi government a comprehensive health care delivery system was developed. In fact they have their dispensaries, they don’t call it primary health centers or CHCs. In urban sector it is called dispensaries. What we’re getting is the infrastructure was used from these dispensaries, what is being recommended as an integrated vision center. The medical officers are there only. In fact, other source of human resource like ANMs, ASHA, other volunteers, were provided through Delhi government dispensaries. Even medicines were provided through dispensaries. What we were giving is one optometrist or one or two field worker as per the need as per the number of people there. And one team was providing services to 2-2.5 lakh population. That is covering around 4-5 dispensaries each team. What we were mainly involved as supervising were record maintenance, daily reporting, they are monitoring use through RP Center and then spectacles were provided on consultation visits and referral services. All referral services were there are RP Center. This is a wonderful model which we adopted and in fact we reached to 28 vision centers. In fact most of these services were sponsored by major NGOs and WHOs, Orbis, CBM and Vision Screen and also Sight Savers. Besides this we took help of local NGO partner like Deepalaya, SSMI, Heromotors and projects were in primary eye care also and rehabilitation also at the community level. This is the list of 27 vision centers in eight districts of Delhi and also in the neighboring state of Haryana. And in both our districts we had two vision centers. This is a list of the centers and the various partners with vision centers were started. In fact I would like to mention here the model with SSMI. Here this is one NGO where all local staff, the community based staff is provided through this NGO. They’re the key managers, they have the ownership, and we’re just sending our optician and one health worker to the centers for screening and referring patients to RP Center. The key services provided in these vision centers are early detection and treatment, first line management of referral cases, even emergencies. I think the most important function is the vision testing and refraction and dispensing spectacles. And in case people need surgery then we do their basic examination and then treatment is given at RP Center. Follow up is done at vision centers and of course the training of human resource, whether ASHA workers or we have other volunteers, they are being provided at these centers. And we are following a model which has been recommended by the government of India that all comprehensive services, that include preventive/promotive, curative, and rehabilitative services should be provided in these vision centers. Of course more importance is given to health education. Daily one health education talk is being given in each center. We have developed this other education material and we were using these posters during the health education talks. In fact as we know that refractive and cataract are key priorities. For cataract we have a reach in program that means screening is conducted with the help of various NGO partners in the community. And patients are brought here at RP Center for surgery. This is for reach in program. And we are doing nearly 3,000 cataract surgeries through vision centers or through outreach screening. Another component which have been added since 2013, is that every month one DR screening in each of the vision center using this non-mydriatic fundus camera. Our optometrists are trained, they are able to screen, they are able to even grade that diabetic retinopathy and all the DR cases are being referred to RP Center. Each vision center is covered once in a month by DR screening. And all these diabetic patients are referred by the ASHA workers and the ANMs, they are working in these centers. In fact one more which I would like to mention is the model which have developed in local centers, where ophthalmologists also work. And we have all the key equipment which is required at the primary level important for recruitment. Whether it’s slit lamp, whether it’s indirect ophthalmoscope or auto refractometer, all of these are available in this vision center. Even a senior resident doctor is available for management of patients. The best part which I can share with you is now we have online entry forms. In vision center there are no hard forms, everything is accessible in a mobile based or be capable of. And our staff, our workers, they’re entering the entire data through that mobile app. And it can be seen easily within two hours time by us sitting in RP Center. And then all the reports are being developed automatically through the software. I wish all of the vision center with different partners they should use this free upload. This is totally free, of course, anyone who would like to use this software, this app, they are welcome, we can help them in these things. All type of reports developed automatically whether it is DR clinic report, whether it is cataract surgery report, it is follow up reports, everything is available online. Another thing which I would like to mention is not only the vision centers, we are working below vision centers. That is the level of health and wellness centers at 1/5000 population and at community level with the help of ASHA workers and then school teachers in the same community. In fact one study, a peer research study, has been done on ASHA worker, how we can strengthen primary eye care services in urban areas using these ASHA workers at community level. Again, health and wellness center also it is not only eye care, we limit it to preventative care, even curative and rehabilitation services are also available in these health and wellness centers. As ASHAs are concerned we have trained more than 900 ASHA workers in Delhi in these vision centers and they are being used for screening and creating awareness in the community. It is just a one year training program that is being conducted in these centers. And in fact this has been the community Delhi government. Also the doctor does a similar training program with all the ASHA workers in Delhi. In fact the emphasis is being given on community based screening for visual impairment and blindness at the community level by these ASHA workers. They’re being involved in awareness generation, screening and identification of blind and visually impaired, referral services. And also improving the follow up services, especially for the cataract patients. Not only ASHA workers, what we have tried is all kind of volunteers are available in community. They are welcome. They have been given training by our teams in each center we are hoping that we should have nearly 30-40 workers who can help us in community linking into the community. I would also like to mention here the role of CBM-RPC Disability Inclusive Eye Health Program. Here we have another approach, we have a partnership with nearly 72 organizations who are being involved in various rehabilitation activity for the blind patients. And there our partners, they are providing rehabilitation and community. We here at RP Center, we provide services, disability certification and if any care is needed. The low vision workup is considered it is done at RP Center. This is a fantastic partnership between local organizations who are providing the rehabilitation services in RP Center with more tertiary care of these patients. In fact one project I must mention with the CBM. In fact when COVID was there, we totally stopped our primary eye care services for nearly three months. Then in fact CBM approached us and they provided the mobile based services so that we can restart our services. I’m happy to share that now we have started services in 18 of our vision centers and we are hoping the rest of the nine vision centers will also start services very very soon. To summarize. The key recommendation from our side for public private partnership at primary eye care level, we definitely need to have vision centers, not only in the rural population but also in urban population per 50,000 population. What we suggest is that in urban population because the logistic population we could have once in a week approach in various dispensaries. That means that the advantage is that we can have more number of patient covered. In our vision centers, we see on an average 50-60 patients per day. One team is nearly covering 300 patients per week. This is quite a good number which you’re able to achieve. The dedicated human resource for eye care at the vision center can be provided by the private partners and I’m assuming is a private partner here because we have partners with Delhi government dispensaries and optometrist can be provided by the private partners. But infrastructure, medicines, volunteers and most importantly the doctors, the medical officers, is through the public partners. We need to provide subsidized, low-cost spectacles to the people who need spectacles. There is need to enroll more primary eye care volunteers like ASHA workers and they are incentive-based workers. We need to provide some kind of incentives to these workers. Comprehensive eye care is needed like prevention, cure as well as rehabilitation. As I mentioned, because cataract and refractive are the eye priorities, we need to give focus on cataract and refractive errors. But of course rehabilitation is also important. Establishing a registry for all the blind patients is the current recommendation by government of India so we should have some binders of registry for blind patients also. I’m really thankful to my team, this entire team, community of ophthalmology, the RP Center, who have been involved in various program including primary eye care. And because of this we could achieve so much of things. Thank you, thank you very much. I welcome any questions if needed. [Phanindra] We move to the next presenter, Dr. Troy Cunningham. [Troy] Yeah. I think before I start I want to thank Phanindra and Mr. Mohanty for giving us this opportunity to share about the public private partnership and it’s very interesting. I’m really happy that I’m following Dr. Praveen because there’s so much that he has said that has laid the foundation of what I’m going to talk about. And I’m going to just do this presentation more in terms of, what has been our experiences, what has been our thinking even as we approach the public private partnership. As well as how we implemented the project. I think the very first thing is we really looked at our work in the past. What have we been doing? What have been the common strategies and approaches that we’ve used? And how can we use some of those, how does it fit into the public sector when we transition the eye care services and integrate it within the government services? One of the things that we also looked at is you know how community empowerment. Be it a private or a public at the end of the day, everyone is serving the community. And the goal is to empower the community. What would those learnings that we had that we could transition when we work with the private sector, sorry, the public sector. We also looked at the capacity building work that we were doing with our partners and how much of these modules and training capsules can be used by the public sector within the government health systems at the state level? Now being very careful to know that we do have within the government system many well developed training modules. It was to really understand what we have, what does the government have? And then try to come up with a module that really is able to combine all of this. I think the most important thing was work in collaboration with partnerships, especially with the Ministry of Health. From very early we did work in different ways. Even though we worked in a community through a private NGO, we always included the ASHA workers into the awareness of primary eye care and the screening at the community level. I think that these are some of the things that really helped us to understand, maybe we are good in terms of how do we develop a model that will work in the government? I think one of the most important things also is to understand within the government. When we are looking at developing a model for the government, we first need to know what is already available within the government, what are their current guidelines and everything? When we look at this you can really see that already there’s an Ayushman Bharat scheme. And within that there are 12 services which are part. And one of the 12 services is the ophthalmic and ENT. I think our approach was really to identify what were those key links within the government, what are their current guidelines, what are their current strategic approaches and then overlay what we have learned into the way we work with the PPP model within the states that we worked in. Once we had got a fairly good idea that there is a very clear structure in place, there are modules in place, there are guidelines in place, there is a clear flow of how the eye services will be delivered. Then we started to look at, now that we know that what is the next thing to know is what are we doing? How does this match up with the strategy of the Ayushman Bharat? I think the key thing is that we looked at what would be those gaps? And when we look at some of the gaps that we, even when working within the private sector, it seems like you’re still working with the same foundational gaps. Poor socio-economic, it’s the same thing with the public sector. In fact, the public sector works more for the focus of the poor socio-economic. When you look at the Ayushman Bharat criteria, there are so many criteria that make sure that the poorest of the poor are the most denied, are the ones that are actually be able to avail of the service. And the other looking at what are the services at the current primary and the next level? The health and wellness centers, the community health centers, the district hospitals, what are the gaps over there? Looking at also the training of the health care professionals within these health systems. And also, of course, we know that there is always a limitation in access to eyecare services. What we understood was yes, there are so much commonality that we work with the private sector, but all those gaps and those areas are also there in the public sector. I think it is even more of a challenge when we look at working with the private sector, with the government systems. When we looked at that we developed what would be our objectives. Yes, we want to promote avoidable blindness, we want to help to empower the communities. If you’re going to do that, what would be, we identified four critical objectives. And so one is how do we help to strengthen? I think it’s not really to take some new model into the public sector, but how to help the government strengthen already the health services that they are providing. It could be as simple as building capacities of the health care providers. That was one of our first objectives. The second objective was the reach. If the services cannot be cascaded down right to the community level then the specialist services then how does tele ophthalmology be able to provide those services? And when we’re looking at the different levels right from the ASHA worker and the community, the health and wellness, either at the sub center or the PHC, then the community health centers that function almost like a vision center and the district hospital for the surgeries. How do we develop a smooth referral linkage so that there is no leaky gasket of patients being lost between one system to the next high system? Definitely at the core of it also is looking at empowering communities. How do we work through the public health system, through the ASHA workers who are already in the field? They are doing so much work, they are doing so much education, they’re doing so much of identification. How do we help them in the way that they screen and then how do we help them in the component of really empowering the community to take ownership and be able to access services? I think these are some of the things that we wanted to look at even when we work with the district unit of the government. Once we did that we looked at first we need to strengthen the system. Which is the possible level for establishing vision centers? The community health centers are there, the PMOA is either posted to these areas or they visit the community health centers regularly. How do you establish the vision centers? Once you establish the vision centers at those locations, vision points further down in terms of PHCs, CHCs, but then the next part is the capacity building on primary eye care services. And then the ASHA workers are already visiting door-to-door. How do they add the eye care screening at their level? And maybe bring the referrals into the health care system, be it the health and wellness centers or the facilities about? Once they have done that, then the patient who’s coming into these vision centers and then some of our work in our CHCs, we found that over six months from five people walking into a center it went up to 25 patients. Obviously the work being done at the ground level in the community and at the health and wellness centers have started to push additional patients up into the community health centers. Building the capacity of the community health centers to provide quality eye care services. And then also ensuring that we are establishing linkages for provision of the free or affordable spectacles. These are some of the challenges where you would diagnose and you would tell a person that they need spectacles, but are we able to provide that for free through the community health centers? And of course, in general overall is looking at at the end of the day having a good robust avoidable blindness-free geography where we are working. These are some of the steps that we worked through when we were looking at how do we work with the public sector. What we did was, we did an assessment and I’m just going to walk through the process using photographs. If you look at the first photograph we had an assessment. Then what were the equipment missing? Spoke to the government system, got equipment in, helped them to set up the unit making sure all the guidelines are in place. And if you look at the photograph here you can see there is an assessment of existing equipment. Is the equipment fully functional? What requires to make that equipment fully functional or is there new equipment required? And then finally you can see that once you’ve done all this then you are able to have a fully functional unit that can provide comprehensive eye care services. Once you’ve done that, then comes the whole capacity building portion. And if you look at it, these are also some of the capacity building training. You can see on one side the PMO is actually having a hands on mentorship from the technical person of how to use the slit lamp and what are they seeing. And on the left side you can see the medical offices, they went through a one day training. And the health and wellness community health officers helping them to understand what is their role, how critical their role is in primary eye care services. And last but not least the foot soldiers. They are so important. Building their capacity to look at quality screening of the patients and referral into the system. And then once that was done then we looked at how do these units now work together? And help them to build that strong partnership with screening in the community, or bringing patients after that for cataract surgeries, or even contacting health education programs. Each photograph depicts an activity that the government system has taken up and owned in the districts that we are working. And last but not least, you know the ASHA workers. The significant capacity building was done to help them on how to do the screening and a lot of effort went in. And it’s amazing to see the way the ASHA workers are able to provide that first set up information, the first screening. In fact just two days back I received a photograph of in Arunachal Pradesh when the ASHA worker did the door-to-door survey, there was a lady, a very senior lady, who was in the field working. And she actually the next day went searching for this ASHA worker and found the ASHA workers and said, “You missed me yesterday when I was not at home. Please do my eye examination.” I think that is really the key thing that you want to look at. If you are able to develop a good system and the community starts to own and starts to demand the services. This is the model that I would like to share that we have done in Arunachal Pradesh. If you look at the geographies that are currently working in Arunachal Pradesh, 10 districts. In Madhya Pradesh we did a piloting in one of the more backward coal mining single districts and the state government has now asked us to scale for 10 districts. Meghalaya, they’ve asked us to do a pan intervention and so that is starting off initially with three as a pilot and then build the capacity of the system to be able to provide the services. And ultimately we do see that there is a fixed time in which we would want to be in these districts. And in three to five years, how do we actually phase ourselves out and the whole government health system runs independently after these few years of technical assistance? Just to share a little bit about some of these successes. Like I told you just now, community member goes searching for the ASHA workers and said to do my eye examination. Here’s a story of a lady who lost her eyesight, thought she would never get her eyesight back. But the community health of the ASHA worker, community health worker met her, and she finally initially did not agree for cataract but then she agreed. And then her sight was restored and she became a contributor to the family by looking after the grandchildren. That is something, these are the successes that we are really looking for through the government health system as they implement these programs. Here’s an ASHA worker who’s talking about how happy she is that she got trained in primary eye care and what she is doing in terms of door-to-door visits and actually assessing the community and then referring them for either spectacles or cataract. There’s a sense of ownership and pride that is coming from the ASHA workers that I’m able to do this for my community in the eye department. We also have this is a health and wellness center officer who said that through this program every month 30 people are coming in getting screened, they’re able to provide free glasses, they’re able to provide for minor medication, and they’re mobilizing their community for cataract. This is really what you want to see at the end that the system really begins to independently provide that quality of service. This is the state program officer and he has been talking about that he’s already on a journey to sustain an affordable manner in which to provide primary eye care. Looking, I like the way he says it and looking in ushering in a paradigm shift for eye care services in the state. Another state, Madhya Pradesh, where we were in Singrauli. The collector and district magistrate, he also. For him it is, yes, now through this model I am able to identify the needs, fill the gaps, I’m able to have a good screening mechanism in my own health system. And I will be able to reach avoidable blindness. I think the importance of your early PPP model is to ensure that the ownership and the drive continues to remain with the government system and they completely own and move the program. I think this is the model that we’ve been working on in these two, three states. And this is the way that we’ve done it and some of the examples of success. Or let us say, initial stories that are coming out in terms of service provision for primary eye care. Thank you very much. [Phanindra] Now I request Ravi Ranganathan from CBM India to have their perspective to PPP and primary eye care. [Ravi] Good evening, everyone. I hope my audio setting is good. CBM, actually we are working with many RIOs but I would like to take two RIOs as examples. And then I’d like to do some highlights of the partnership and the impact of the program. The first question is why to have a partnership and why the RIO led model in public private partnership? It’s very important, the strategic answer is that the RIOs are the apex eye care institute. At the state level, regional level they’re offering direct comprehensive eye care services. It is also good to have the kind of subspeciality, tertiary speciality available at that geography and region. And also it’s easy for us to really build a pathway system. Because RIO was also working with communities and they’re also working with some of the primary health centers, community health center and thought it was easy to really build the system. The partnership? So far we have established our partnership with 10 RIOs in the country. This is actually, you need to really appreciate in turn the RP Center because we have a partnership. I want to really thank Dr. Praveen also. He was referring CBM partnership. This helped us to really further partnership with RIOs. We have two programs which we have partnered with the RIOs. The one is the low vision and rehabilitation services. We directly established services at the lowest level. And the second program that we are partnered with the vision center in public health center. This particular presentation I’m going to talk about on the vision center model. This is our model. What we did in this one vision center in rural Bangalore that is at Rohtak Haryana. We have our two staff model, one vision technician, the other one is a community mobilizer. And we have a standardized recruitment which normally we do in any vision center for comprehensive screening. And we have a vision center management software also in built with the computer in the vision center. And the vision center can have a teleconsultation with RIOs at district hospital. We also started doing the dispensing as a pilot spectacle dispensing. Value added services like BP apparatuses and glucometer are also there to really give motivation for the patient to visit. We also do various community outreach, sensitization activity, community level screening and awareness creation, training, et cetera. The most important component of the project is involving the front line workers of the government systems and referral pathways and linkages right from the village to the vision center, from the vision center to the second and tertiary level. We work with very important key stakeholders, the chief medical officers, the medical officer obviously, particularly this is where the vision center is being operated. And our investment mainly on equipments. We had piloted this project for about three years project so it involves a lot of cost and human resource. And also CBM we are doing this inclusive vision center so making barrier free at the vision center we do some accessible features. Here the graph is very clear. I’ve just taken a PHC model and CHC model. When we were doing this, establishing the program we could, even in this short span last year we could really witness that the minimum threshold is 25 patients visiting the vision center to establish primary health center. And the same way 45 is the threshold for CHC vision center. That is the minimum threshold patients that are coming. On top of that, the community mobilizer goes to the community for door-to-door screening and referral patients to the vision center. On top of that the frontline workers: ASHA, ANM, all these including the PHC paramedicals, they were sensitized and they were also contributing to sustaining and running this module very effectively. Especially the ASHA and the ANM are the key role, they play a very key role in the referral pathway system. I had just taken the last one year data, last financial year. When we’d taken these two vision center, one in the PHC model and other one CHC model. We kept the average 5,400 as the target. At the end of the year you can see that target was reached 11,732 which is around 217% and 6,000 is the patients that were additionally seen. Similarly these numbers for screening and diagnostic at the vision center. We didn’t include the house-to-house and community screening numbers. When we look at the spectacle advice from the vision center we ran, again, if you look at it’s double the targets were higher. Targets were 3,000 and achievement is more than 6,000. And 210% were our achievements. And key indicator the person with the disability screened at the vision center also increased. These are the very clear indications that the vision center are established in the public health sector which is very well accessible to the marginalized and then the most vulnerable community. In this model we have found some of the key findings while limiting the project. As I said, the person with the disability and marginalized community are accessing eye care services. Imagine the stories like somebody, a person with a disability, somebody else to accompany and in normal scenarios people travel up to 400 kilometer. They wait for a camp to connect it. These are the challenges that are really addressed to really establish the vision center in the country be it PHC and CHC. The number of walk in an OPD in the previous slide I shared, was really, really high. I compared it with the vision center we run directly with our partner location, NGO partner, in a private hospital. And we are comparing the numbers with the PHC and CHC. It’s very clear that the model with the government, the health system centering model, which is really attracting more patients. Comprehensive screening and patient’s loads are managed efficiently by vision technicians. There are two reasons, one is the RIOs. When we placed the technicians in the vision center they do 10 days of orientation and training the RIOs. Any new recruits they go to the RIOs they were trained on from previous training. And the very important one is to really appreciate the standard equipment and on time service that’s really one of the key for the success. The referral systems are linked already with the district hospitals/RIOs for secondary and tertiary services. It is not just people are seen at the primary level and then the surgical and other intervention at the second and tertiary become a challenge. The services are linked and it’s easy, as I said in the first slide, while working with RIOs linkages work very smooth. And capacity building of the front line workers, allied health workers, in the initial state we did it and it’s become routine. It’s become regular practice that the health workers identify the patients and they refer to the camp, they refer to the health care screen, they refer them to the vision center. Even some of the post surgery follow up, post optical dispensing follow ups have been done by these front line workers. One key thing also I was looking at the because we don’t charge at the level, at the vision center level. It helps that even the people that are poor and very much marginalized community they still gain access to these services. And the existing public health referral pathways between the PHC, district hospital, and medical colleges, the existing health systems and their pathways have become value addition for this particular eye care program also. Based on our learnings and our experiences we would like to recommend two things. The model of integration of eye care can be scaled up with the public private partnership model wherever is feasible. Especially in the first presenter Dr. Praveen Vashist, mentioned that there’s a lack of system and level of services in the country. It’s very well not everyone. There is a need for advocacy for the post of permanent ophthalmic technicians. The vision center projects end with the public private partnership we just continue sustaining after the withdrawal of support. In government set up, it depends on the state to state but in some states there are few people are there. They were not trained well. There is a need for us to really train the existing ophthalmic assistants to do the comprehensive screen. Also advocacy for recruiting more people. I have seen many state governments they’re given a government settler and announcement that they’re going to recruit so many ophthalmic technicians throughout the vision center. That is one important advocacy point for us, especially through Vision 2020 we can take it up with the various government and ministry level. Even at the state level also. And creating a referral pathway to secondary and tertiary centers because the government, it should not be limited with the government secondary and government tertiary services. The referral also can be linked with a private and NGO hospitals also. This way it’s really very collaborative where it’s a mutual benefit for the public/private players in the region. Access to spectacles and assistive devices need to be developed and integrated within the government systems. It’s a case-to-case scenario changes in the various states but there is a need for spectacle and assistive devices. This is the number that I have taken because sometimes back we were taking Karnataka health system model. The statistic is very clear that the number of sub centers and we have about more than 2,500 of PHC and 204 CHCs. 146 Taluk hospital and district hospitals. It’s very clear that these centers, these hospitals, do not have adequate human resource and recruitment and other requirements and resources. There is a need for public private partnership to strengthen this. And while addressing this we can very well address the health systems and we can address the government to take care of the eye care requirements. There is also some value added services can be done with the model. As we said the scaling of the vision center in other CHC/PHC, there is a lot of scope. And training of all government vision technicians on a comprehensive screening at the RIOs which can be taken up. DR screening at the vision center level and mobile unit for DR screening. And even RIOs there’s a teaching institute they can have at least some people are dedicated monitoring and doing tele consultations also possible. All this is what we are expecting of the outcome at the end of the project is that the good policy in place and regulations and organization structures and human resource to address the huge back level of eye care program in the state. That’s all from our end. Thank you so much. [Phanindra] We have a good number of questions but we can take up. I request my colleague, Anindita, to facilitate the Q&A session please. Anindita, please? [Anindita] The first question is any opportunities for PPP models in eye health care in Gurgaon, Haryana? [Praveen] Yes, sure, in fact we already have three vision centers in Gurgaon, Haryana. Specifically in the rural areas and one in Sohna, Tauru, and also with Hero Motors. What we have is we have some kind of association with Depahlia for two vision centers and Hero Motors with one vision center. They are sponsoring us. And I believe this Arondia Gurgaon, they are also a good agency with availability of optometry centers and everything. They can also try similar model and do provide services through their vision centers. I hope it is okay. [Anindita] The second question is Praveen, sir, for you. Please let us give more details about ODK application at a vision center level data management. [Praveen] Sure, actually ODK stand for Open Data Kit. It is available through your phone. And what we do is our programmer and data entry operator, they developed a kind of mason Excel sheet base to be whatever performer is there, that is in Excel sheet form. And ultimately that turned into a kind of ODK mobile lab and anyone can download it, anyone can download. Totally free, of course. Next time it is on servers. Whatever data entry you were doing at the level of vision centers that need to go to a server. In the AIIMS we have our own server, it is available to only free of cost for us. But if any other agency is planning for this system, then they have to arrange their own server for this thing. Once server is there and entire data has been entered by the people, and through the server we get downloaded through CS Freewhites. And then we have developed a data program and through these data programs we have developed coding system as well as a monthly reporting system. And then all kinds of report will we want that is being developed through that data CSC data and using this data program. If any agency wants these things, we can help definitely. But the only thing they have to do is to arrange a server for their institute and then it will. I hope it is. Thank you. [Anindita] Thank you, sir. Sir, another question for you. Have you treated people with leprosy having eye problems, particularly lagophthalmos? [Praveen] Yeah, actually what I feel is really the perseverance of leprosy is quite low. And if any such cases are seen in vision centers, then we have a fixed number of diagnoses, 17 diagnoses. They’re not making this a lid problem because of leprosy. They will just write that specific diagnosis. Overall with the help of this data management system is difficult for me to exactly give whether it was a leprosy patient, a lid problem or something else. Any such kind of patient we have a separate unit to deal with such patients. And they are being referred to RP Center and I’m sure all the services are available to this patient. As far as the limited data managing system is concerned, I can’t exactly give you whether this was a problem because of leprosy or because of some other disease. [Anindita] The next question is again for Dr. Praveen. Which model will you advise? It’s the fixed primary center or mobile center? And how teleophthalmology is helpful? [Praveen] In fact we can have a debate on this thing, which model is better. Sometimes it is a mobile based system is better, sometimes a fixed facility is better. But in general now looking into an integrated vision center approach, we’re looking forward that a vision center is there with availability of medical offices and comprehensive services are there, and eye care is embedded in that. That is directly leading to a fixed facility center model. Some people feel that mobile vision centers may be cost effective. You can take them anywhere, any places, but some research has been done by London School of Hygiene and Tropical Medicine by Dr. Rajesh Dopsie. And where he has come out that the cost of services through mobile centers are higher compared to the fixed facility method. But as on today, I can tell you very well looking into the latest integrated model that we are directly going towards the fixed facility integrated primary eye care services in primary health centers or in government dispensaries. But just added one complimentary into the system. Teleophthalmology definitely it is important. We have a very good example in urban eye care system in LV Prasad. They are using their teleophthalmology services at the level of vision center. That means the vision technician, we all know that he can’t prescribe medicine officially. They are using this opportunity that they are sending data through teleophthalmology and people sitting at the base hospital ophthalmologists or medical officers. They prescribe or they make the final diagnosis and prescribe medicines. In that way when optometrists are not allowed to prescribe any medicines, they are not capable of making a final diagnosis in general. They may make a kind of screening based diagnosis. Then probably tele ophthalmic services are important. And at this stage in country after this COVID pandemic, probably we find that teleophthalmology further developed. It is developing and people will have this in their vision centers. I hope it’s okay. Next please. [Anindita] Thank you, sir. The next question is for Dr. Troy. How do you approach donors, corporates, and individual that is meant to get involved in eye care? [Troy] Thank you for that question. I guess if I have a completely perfect answer to that I’d have a much bigger hold of money to be able to work with. But yes, definitely it is a challenge because you’re always competing versus other health portfolios like Maternal, Newborn, Child Health where you’re really addressing maternal deaths, you’re reducing maternal deaths, neonatal deaths. Or you’re looking at tuberculosis where you’re actually reducing TB cases, saving lives. And so a lot of times the question is eye care saving lives? How do you string that together? I guess it’s more in terms of what we do is quality of life. I think that’s the important message. That is one of the first important messages. Secondly is do we have robust sustainable models to showcase? No donor definitely wants to be tied up with you for years and years over a decade. But at the end of the day you definitely are looking at being able to showcase models that have been able to achieve it’s public health goal within three to five, if not maximum, seven years. A lot of the other health portfolios if you look at the other health domains, they do also have a five to seven year fixed time where the impact at the community level is achieved. The important thing is what do you take to the donor? If you take something that very clearly talks about a very structured strategy, very clearly indicating outcomes, your past experiences of what you were able to do. A simple example of what I was able to just show you. It’s really not just in terms of large numbers covered or so many services provided but when you hear from the community itself, “My life was changed.” The health system saying that from five people walking in to 30 people walking in. I guess those are the key things that we need to be able to showcase to the donor and also I think the question even Dr. Praveen is talking about. How do you make sure your data is valid? How do you know that you’re able to showcase quality data? That’s something that these are some of the few things that the donor looks for. Yes, it’s an ongoing learning process. I guess we are all still learning how to get the donor to actually come in in terms of eye care services. But these are a few trips that would help anyone to be able to approach donors and be successful at the end of the effort. And of course be realistic. You could possibly go to 10 donors and you’d probably get one or two. Not that you would get 100% so every effort results in funding that comes. These are a few very broad ideas that I could share. Thank you for the question. [Anindita] The next question is what is the plan for sustainability once the program funding is over? [Ravi] Can I respond to that? [Praveen] Yes, please. [Anindita] Yes, sir. [Praveen] I just take my experience working with these RIOs and the various state governments. The thing is if you look at largely a lot of vision centers should be established, that’s a really ambitious target. Imagine the number of vision centers which are established with this model, public private partnership model, what happens now after we withdraw this project, the funding. There are shortcuts are there and there are longer to achieve there also. The shortcut is that as I said there are vision technicians that are already there in the health system. But some vision technicians are placed in the PHCs or CHCs where there is no equipments to screen. There is no service and treatment. And there are some technicians that need some training but they’re already in government care. Immediately when the projects are withdrawn, the government actually we are working with health secretary at the NPC level of medical colleges. Their response is once you enter the minimum assurance is that we will place the vision technicians already in the government set up. The longer is that we need to really take advocacy, not only just working at the PHC level alone. We need to really have some kind of lobby and advocacy meeting with the workers at the state level, the regional level, to really make the provision of vision technicians available. The most important one is the NGOs and the corporates can easily resource for their establishment costs. Like we can find the equipments, procure and give it to them, that’s not a problem. But the problem is the running costs. When it comes to the operation already the vision center is the PHC. You don’t need to additionally make any running costs like water, electricity, something you do for the private vision center. Such issues is not there because the expenses are already covered by the PHC/CHC usage and their infrastructure. But what is most important, the one is the human resources cost which need to be looked at and the option is there to immediately relocate the people in the vision center. And then go for the long term advocacy to really keep adequate manpower to the system. Also very important like different players have a different role to play. Some corporate, they have some devices they want to really use it for door-to-door screening or primary eye care screening. The corporates can offer that kind of low cost medical devices which are already available. Many corporates will reuse that small device. It can do the refraction very well, an eye screening very well. Those types of small contribution from various corporates can help screening at the community level. Collect your efforts and join your plan with the government and corporate will definitely help those schemes as a model. [Anindita] Thank you, sir, the last question. [Troy] Can I just, I have a small point. I guess a very simple control is when you’re looking at sustainability is the more you’re investing in initially, there’s a lesser chance you’re going to be sustainable. Being able to work within the systems of what’s available. Looking at even though the Ayushman Bharat, the equipments can be procured, the HR can be requested through the PIP annual and semi annual processes. Very simple thumb rule to use if you’re going to be significantly investing in the program, then you’re going to be there for a long time and you will also possibly have a lesser chance of sustainability. If you look at the programs that we implement, the integration of eye care into the public health systems is one of the least expensive models for us. Because we are very cautious not to get into too much of, you don’t want to replace what the government can do. And it may take a little longer time but they’re also committed along with you. And they make sure that they’re able to get some of the staff, they’re able to get the equipments. A simple thumb rule is if you’re investing too much it’s going to take you that much longer to come up. [Anindita] Thank you, sir. The last question is how do we get the mobile application from RP Center? [Praveen] The fact is, it is not our right, actually, it is available only free of course. You type Open Data Kit and even the process how to use it is also available. But still if somebody is not able to understand they’re welcome, one day they can come to RP Center. It’s just a one day process. And one of our programmers will help them how to use it. Free of course, as I mentioned. Only thing they should have is a proper server, their own server. With their forms that they want to develop, that similar forms can be developed through this open data in Excel data. It is, I’m very clear, it is not our copyright on this thing, it is totally free. And somebody can easily check it through Google and then they can get it. [Phanindra] At the end of this session I would like to really thank once again, CBM, Operation Eyesight Universal, RP Center, AIIMS, all the participants and our cab members, and Cybersight. With this remark I would like to thank everybody once again and conclude this webinar. Thank you so much.

August 1, 2022

Last Updated: January 11, 2023

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